Primary Care Coding Alert

Question: How would you code the following?

Chief complaint: Patient is here for a sick visit. Patient complains of severe headaches and sore throat for 3 weeks.

HPI: Patient is here for an acute visit. Has completed Z-pack and reports some decrease in nasal congestion since her previous visit on 2/17/2017. She reports initial improvement in fevers and chills; however, fevers and chills have returned — Friday evening fever of 101.3 F, and fevers and chills last night. She also reports chest congestion, constant cough with some production, some shortness of breath with coughing, and chest/rib pain. Also describes a pinching pain and swollen painful throat. Reports fatigue. She denies nausea and vomiting. No shortness of breath or chest pain at rest.

PFSH: Childhood Illness/Past Medical History: 1. Diabetes mellitus 2. Hypertension 3. Hyperlipidemia 4. Dermatophytosis 5. Vitamin d def.

Past Surgeries/Procedure: 1. Gallstone surgery 2. hysterectomy, fibroids 1999 3. cyst removal 13 yo.

Social History: The patient is single and has 3 children. Her highest education is college and she is a student. The patient has never smoked. Her caffeine intake is 12 cups/day. She is a social alcohol drinker. She never exercises. She never takes drugs.

ROS: Patient complaints per HPI.

Vital signs: Weight: 268 lbs. Height: 5 ft, 4 in. BMI: 46.0. Temperature: 99.6° F. Respiration Rate: 18. Oxygen Saturation: 98% on room air at rest. BP: 148/98. Sitting, Heart Rate: 107. Rhythm: Regular. Volume: Normal. Character: Normal.

Exam:

General — Well developed, well nourished, normal alertness, appears fatigued.
Extremities — No ulcerations, no edema, no cyanosis, no lesions, no varicosities.
Cardiovascular — Regular rate and rhythm, no murmurs, normal heart sounds.
Respiratory — Spasmodic coughing on deep inspiration;rhonchi that cleared with coughing was noted on the upper lobe of the left lung; normal breath sounds of the lower lobes of left lung and right lung; no tenderness to palpation of the chest wall.
Gastrointestinal — Soft to touch, no distention, positive bowel sounds

California Subscriber

Answer: Based on the information recorded by the provider in the chart, you can code the following:

Current assessments:

• J39.9 (Disease of upper respiratory tract, unspecified) (based on the patient’s previous visit and the continuing conditions)
• Z68.42 (Body mass index (BMI) 45.0-49.9, adult) (based on the patient’s continuing BMI of 46.0)

Procedures:

• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity ….) (based on a detailed history, which includes an extended history of the present illness; a past, family, and social history; an extended review of systems that includes a problem-pertinent system review with a review of a limited number of additional systems (4); and a detailed exam of the affected body area(s) and other symptomatic or related organ system(s). This meets the “two-out-of-three” rule for the level of the service)
• 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination)  
• 3008F (Body Mass Index (BMI), documented (PV)) (Per CPT^®, use of this Category II tracking code is optional)

Coding alert: Per National Correct Coding Institute (CCI) edits, 99214 is bundled into 94760 unless an appropriate modifier such as modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) is appended to 99214. However, some payers, including Medicare, regard the procedure as included in the evaluation and management (E/M) service or any other service billed on the same date. Code 94760 has a status “T” in the Medicare physician fee schedule, which means it is only paid if there are no other services payable under the physician fee schedule billed on the same date by the same provider.

If any other services payable under the physician fee schedule are billed on the same date by the same provider, this service is bundled into the physician services for which payment is made. So, you will probably not receive separate reimbursement for the 94760.